A rapid increase in coverage of COVID-19 vaccination, Central African Republic

Abstract Problem In 2021, Central African Republic was facing multiple challenges in vaccinating its population against coronavirus disease 2019 (COVID-19), including inadequate infrastructure and funding, a shortage of health workers and vaccine hesitancy among the population. Approach To increase COVID-19 vaccination coverage, the health ministry used three main approaches: (i) task shifting to train and equip existing community health workers (CHWs) to deliver COVID-19 vaccination; (ii) evidence gathering to understand people’s reluctance to be vaccinated; and (iii) bundling of COVID-19 vaccination with the polio vaccination programme. Local setting Central African Republic is a fragile country with almost two thirds of its population in need of humanitarian assistance. Despite conducting two major COVID-19 vaccination campaigns, by January 2022 only 9% (503 000 people) of the 5 570 659 general population were fully vaccinated. Relevant changes In the 6 months from February to July 2022, Central African Republic tripled its coverage of COVID-19 vaccination to 29% (1 615 492 out of 5 570 659 people) by August 2022. The integrated polio–COVID-19 campaign enabled an additional 136 040 and 218 978 people to be vaccinated in the first and second rounds respectively, at no extra cost. Evidence obtained through surveys and focus group discussions enabled the health ministry to develop communication strategies to dispel vaccine hesitancy and misconceptions. Lessons learnt Task shifting COVID-19 vaccination to CHWs can be an efficient solution for rapid scaling-up of vaccination campaigns. Building trust with the community is also important for addressing complex health issues such as vaccine hesitancy. Collaborative efforts are necessary to provide access to COVID-19 vaccines for high-risk and vulnerable populations.


Introduction
In 2021, as countries worldwide were rapidly rolling out their coronavirus disease 2019 (COVID-19) vaccination programmes, Central African Republic faced major challenges in vaccinating its population against COVID-19. 1 The country's health services were contending with delays in receiving required vaccine doses, shortfalls in operational funding, low storage capacity for vaccines and a shortage of health workers. 2 The reluctance of people to be vaccinated was also a challenge, given the country's diverse population and low levels of education. We describe the health ministry's strategies to surmount these challenges and increase the country's COVID-19 vaccination coverage.

Local setting
Central African Republic is a low-income country that has undergone a series of military and political crises which have caused immense damage to the already weak economy. The result is poor infrastructure, a deficit in medical and paramedical personnel and the absence of government health workers in some of the seven regions. The population was estimated at 5 570 659 in 2022, 3 among whom 3 509 515 (63%) were in need of humanitarian assistance. 2 The country is ranked 188 out of 191 countries in the 2022 Human Development Index. 4 Central African Republic began vaccination after receiving its first COVID-19 vaccine stock in May 2021 from Democratic Republic of Congo. After several interruptions in vaccine supplies, vaccination resumed in January 2022. 1 COVID-19 vaccination was not mandatory in Central African Republic, although a law on vaccination of children was enacted in 2021 after the high-level forum on vaccination of November 2020 in Bangui. Despite two major COVID-19 vaccination campaigns (in September and November 2021; Fig. 1), by January 2022 only 503 000 (9%) of the general population of 5 570 659 were fully vaccinated. 5

Approach
To increase COVID-19 vaccination coverage, the health ministry applied three main approaches. The first approach was task shifting to redistribute tasks among community health workers (CHWs) to address the shortage of healthcare workers. 6 Task shifting has been found to be effective in ensuring equitable access to vaccines. 7  The approach involved training 578 CHWs on COVID-19 vaccination protocols, safety measures and data collection 8 through a cascading training method. Trainers at the health ministry developed the training materials, which were then taught to trainers at the regional and health district levels. These trainers, in turn, trained the CHWs in their respective districts. Prior to each of the vaccination campaigns of September 2021, January 2022 and August 2022, two-day briefings were provided in their respective health districts to ensure that CHWs were upto-date. The health ministry ensured the effectiveness of the delegation of tasks by using results-based financing, which linked performance-based purchasing to minimum vaccination targets. To ensure accuracy, supervisors who were health workers from the health ministry and knowledgeable about results-based financing were deployed to verify the reported figures.
The second approach was gathering evidence on vaccine hesitancy within the population to understand the factors that may influence individuals' acceptance or rejection of the vaccine. In July 2021, a consultant from the European Agency for Development and Health conducted a social survey to investigate the determinants of acceptance of vaccination against CO-VID-19 in the country. 9 The study aimed to collect data from 439 individuals, using non-probability sampling techniques such as observation, reasoned choice, and convenience and snowball sampling. The researchers employed various research methods including documentary research, questionnaires, individual interviews, field visits and observations. The primary objective of the survey was to gain insight into the attitudes, beliefs and behaviours of the population towards vaccination against COVID-19. The findings revealed that 294 (67%) of the 439 people sampled would accept vaccination if country, religious and community leaders were vaccinated first.
Survey teams also conducted 16 focus groups to investigate attitudes towards vaccination. Each group had up to a dozen individuals discussing predetermined topics, and sessions typically lasted 60-120 minutes. The groups met only once. The groups included young people, elderly people, health personnel, religious leaders, traditional healers, journalists and representatives from the health ministry. This approach emphasized engagement with community leaders, health-care workers and diverse populations to build trust and address the specific drivers of vaccine hesitancy in the country.
The third approach we used was to bundle COVID-19 vaccination into a package of existing health interventions to address the scarcity of resources and the low vaccine delivery capacity in the country. The health ministry organized two rounds of polio vaccination campaigns in May and August 2022, targeting 1 310 108 children younger than 5 years, (655 054 children in each round). 10 COVID-19 vaccination was incorporated into the planning stage of polio campaigns by the development of a joint microplan, and involved  Lessons from the field COVID-19 vaccination, Central African Republic Adidja Amani et al.
several steps. First, we assessed the feasibility of conducting both campaigns simultaneously. Second, we added the COVID-19 vaccine to the list of vaccines to be administered during the campaign. Third, we planned the distribution, storage and transport of vaccines, as well as the monitoring and reporting, to ensure that both vaccines were available and administered safely. Fourth, we developed social mobilization and communication strategies to encourage community participation and increase awareness of both vaccines. This plan included mapping of the target populations for both vaccines, as well as identifying and training staff capable of administering both vaccines. Overall, the design process allowed us to deliver COVID-19 vaccinations and decrease the overall cost of service provision.
The polio team used their community engagement strategies to promote COVID-19 vaccination alongside their polio campaign. They used established relationships with community leaders to spread awareness about both vaccines through various channels, such as door-to-door visits, community meetings, mass media campaigns and social media. The team worked with local health authorities to address concerns and share reliable information for safe and effective vaccination.
Temporary vaccination posts were set up in different locations, preferably under trees and away from the sun, during vaccination campaigns to provide vaccination services in places where people gathered, such as markets, churches, community leaders' homes or other public areas. In some cases, the health posts were moved daily, while in other cases, they remained in the same location for a longer period to ensure that the target population had access to vaccination services throughout the campaign. Around 20% of the vaccinators for polio were assigned to vaccinate against COVID-19. The vaccinators assigned to poliomyelitis were mobile, while those of COVID-19 were restricted to vaccination posts.
To analyse trends in coverage of COVID-19 vaccinations over 2021-2022, we used routine administrative data and conducted secondary analyses of quantitative data from the health ministry database and campaign data.

Relevant changes
Efforts to surmount the challenges of COVID-19 vaccination in the fragile setting of Central African Republic soon showed results. Vaccination coverage tripled from 9% in January 2022 to 29% (1 615 492 out of 5 570 659 people) in August 2022 (Fig. 1), with the Janssen vaccine (Janssen Therapeutics, Beerse, Belgium) being the most widely used in the campaign. Fig. 2 shows that as the number of COVID-19 vaccinations increased, there was a corresponding decrease in the number of reported cases of COVID-19, with the steepest decline observed once the primary series coverage reached 14% of the general population.
Evidence obtained through surveys and focus group discussions enabled the health ministry to fine-tune the vaccine campaign messaging. Awareness-raising was bolstered via a series of interactive community radio broadcasts between the health minister and the population in the local language, a move that helped dispel vaccine hesitancy and misconceptions. Task shifting within existing CHW networks enhanced access to hard-to-reach communities, boosting the nation's overall COVID-19 vaccine coverage. Moreover, the integrated polio-COVID-19 campaign enabled the country to vaccinate 136 040 and 218 978 people in the first and second rounds respectively, at no extra cost. Up to 10 September 2022, a total of 113 084 people had received booster doses, representing 7% of the 1 615 492 vaccinated people.

Lessons learnt
The integration of the polio and COVID-19 vaccination campaigns brought with it many challenges, notably the insufficient number of vaccine carrier boxes and the use of a paper-based data management system. Although vaccination was integrated, the polio and COVID-19 vaccination campaigns had different data collection tools, which doubled the workload on health workers who had to fill out separate forms. The paper-based data collection methods were also prone to errors, leading to incomplete or inaccurate data and data loss. To overcome these challenges, lengthy telephone calls were held between central and district health authorities to actively collect the data for COVID-19 vaccination, and at the end of the campaign, we held evaluation meetings, inviting all 35 districts to ensure complete data. These challenges highlight the need for integrated data tools in bundled mass vaccination campaigns (Box 1).
Task shifting proved highly effective and was widely accepted in the administration of injectable COVID-19 vaccines. However, the deployment of CHWs in certain areas presented challenges, as some CHWs were posted in districts where they were not familiar with the local communities. As a result, there were sometimes misunderstandings and a lack of community trust in the campaign which hindered CHWs' ability to perform their duties effectively. This experience demonstrated the importance of respecting community involvement in the selection of CHWs to build trust and increase acceptance.
Collecting data in challenging environments can be a daunting task, as evidenced by the Social Survey on Determinants of Acceptance of Vaccination against COVID-19 in Central African Republic. 9 Due to infrastructure limitations, security issues and the inaccessibility of some districts in the rainy season, we were only able to include six out of the 35 health districts in the social survey. By introducing electronic data collection methods using the Kobo-Collect mobile application (Kobo Inc., Toronto, Canada) and online collection methods, we have increased the total number of districts to 18, representing 51% of the total number of districts. Moreover, the introduction of mobile tablet computers for data entry and  Leçons tirées Solliciter les ASC pour la vaccination contre la COVID-19 peut représenter un moyen efficace de renforcer les campagnes déployées. En outre, établir une relation de confiance avec la communauté est essentiel pour répondre à des défis sanitaires complexes tels que la réticence face à la vaccination. Des efforts sont nécessaires en matière de collaboration afin de garantir l'accès aux vaccins contre la COVID-19 aux populations vulnérables et à haut risque.